Things to Remember About Seizures

A young man who was admitted with a seizure. He had a childhood history of seizures but had not had an episode for 10 years.

The previous evening, he had been awake until 4am and had not eaten any breakfast the following morning. At 11 am he had a seizure that was observed by his friend and this was Tonic in nature and associated with the apnoea and cyanosis. The patient did not bite his tongue and had no urinary incontinence. In fact, the patient had some retrograde and antegrade amnesia for a short period prior to and after the seizure, and he could not remember getting up from the floor and walking around in a confused manner following the seizure.

He had no other relevant previous medical history and took no regular medications. He drank no alcohol but smokes. He has never driven a vehicle because of his fear of seizures.

On further questioning, he explained that he had new back pain. He also had a slight headache but no neck stiffness or photophobia. It was noticed that he had a swollen Right upper eyelid and he was asked if he had bruised his eye from the fall with seizure. In fact, he reported that he had developed an eye infection several days ago and had been using antibiotic drops. These drops had been opened 2 years ago and had not refrigerated-- thus, they were likely to be contaminated. The drug was Levofloxacin.

On examination he was afebrile but felt warm to touch. He was alert and jovial.

Vital signs were otherwise normal. In fact, all of the physical examination including cardiovascular, respiratory, abdominal, CNS and PNS exams were entirely normal. He had a bruise over his right upper back that was fresh but not painful when pressing the ribs. He denied any vertebral body pain. He had no neck stiffness.

Blood results were normal except for a raised white cell count that was consistent with a recent seizure. CRP was normal.

Chest Xray was normal with no rib fractures present. CT head showed a normal brain.

So, this man had a Tonic Seziure and this was on a background of previous epilepsy plus recent tiredness and possible hypoglycaemia. I say possible hypoglycaemia because no blood sugar was taken to determine this. The patient had been taking out-of-date Levofloxacin eye drops and any eye drop can get into the systemic circulation. If one checks the side effects of Levofloxacin, one such effect is Seizures !!

Hence, there may possibly be a Drug Induced effect from a fluoroquinolone drug.

Things to Remember:

• Ask the patient about every abnormality you see e.g. bruised eyes, grazes to skin, wounds etc. DON'T TAKE IT FOR GRANTED that the problem is due to the current problem e.g. in this case falling over with a seizure. As is clearly demonstrated in this case, asking him about his eye revealed that he was taking an antibiotic which can cause seizures!

• ALWAYS check if patient has signs of Meningitis

• ALWAYS check the Blood Sugar

• TAKE A HISTORY of things that cause the seizures e.g. lack of sleep, hypoglycaemia, flashing lights, alcohol

• FIND OUT if patient drives a vehicle! If they do, they should be advised to STOP DRIVING. You have a responsibility to the patient and the general public to inform the patient about driving cessation from epilepsy

• Check URINE as UTIs can induced seizure in persons with history of seizures.

• ALWAYS, ALWAYS, ALWAYS ASK ABOUT DRUGS and PLEASE check the drug side effects and ADVERSE REACTIONS PROFILE as in doing so, you may find out that the drug induces seizures.

• REMEMBER THAT RAISED WHITE COUNT DOES NOT ALWAYS MEAN INFECTION; the process of seizure activity causes white cells adherent to the vascular endothelium to fall off into the blood stream thereby elevating the peripheral circulating white count.

Have a nice weekend!

Kyorin Daigaku-- Dr Stein and Dr Aoki

Last night I attended Dr Stein and Dr Aoki's combined conference hosted by Kyorin Medical School and organised by Dr Saraya (Kampo Master)

Dr Stein talked on aspects of physical examination for determining common rheumatologic diseases including rheumatoid arthritis, osteoarthritis and gout.

Dr Aoki posed many intelligent and probing questions to Dr Stein throughout his two hour lecture along with very good questions from the doctors and students sitting in the audience.


I was able to learn from Dr Stein's rheumatological experiences in Japan over many years and his opinion on doses of DMARDs such as Methotrexate. Moreover, I was particularly happy to see only a few xrays and with the talk concentrated on symptoms and physical signs.

Not a CT or MRI in sight. How refreshing :) !

Amazing Prof Stein

Today saw the return of Prof Stein to Japan for teaching his famous Problem Oriented System at our hospital.

He is quite an amazing person as despite a grueling flight from Florida yesterday, he was ready for lectures in history taking and physical examination and problem solving.

We had two exceptional cases, one of Wernickes Encephalopathy and one of bacterial pericarditis.

The famous Dr Makoto AOKI was also in attendance in the afternoon for the infectious disease case and he was able to provide his expert opinion along with Prof Stein's dissection of the case and evaluation of the data.

Prof Stein's system is very useful and it helped me to make difficult cases far more logical to interpret as a medical student and as a junior physician.



I now teach a similar way to Prof Stein with a British system emphasis on physical examination in addition to use of relevant history taking plus differential diagnosis formation.

Tomorrow sees yet more great cases for Prof Stein to solve and I hope the Jet-Lag with not be a problem for him.

I think this is a good opportunity for our residents to learn medical English plus other medical concepts that are more common in foreign countries.

Tomorrow is also the last day for my apprentice medical student from Kyorin University. I am hoping that he will be able to produce a summary of his experiences to publish on this blog. I hope that he will consider returning for residency at this hospital.

Measles

The following includes two cases of Measles in as many weeks, both in adults. The first case was a female patient who had not be vaccinated.

She had a mild rash, fever, conjunctivitis and Koplik spots. She did not appear to have any remarkable systemic compromise. She was allowed to go home but restricted to her home until she became well-- a self-imposed quarantine.



The next case was a young adult male with a one week history of fever, sore throat, malaise, rash and vomiting. He too had been unvaccinated.

He was severely unwell with a high fever and sweating. He had multiple Koplik spots, a peripheral blanching maculopapular rash, although on his face, the rash had become confluent. Examination of his chest revealed reduced air entry at his left base and abdominal examination showed mild hepatosplenomegally. This was indeed a severe case and a primary measles pneumonia was suspected. Liver function tests were mildly abnormal consistent with the physical findings.

There has now been an explosion of cases of measles of epidemic proportions and these cases have also occurred in the unvaccinated adults.

With myself being trained in immunology, I recognise how important it is to adequately immunise the children and adults alike in an at risk population. The take up of MMR is Japan has been inadequate and even some doctors that I know have never been vaccinated and are therefore at risk.

Immunising the bulk of the population generally ensures that such an infectious and potentially fatal illness cannot take hold in the population at large. Those individuals not immunised are protected by the 'herd immunity' of the population already immunised. However, if the take up rate of vaccine decreases, then a hiatus occurs which allows the infection the ability to return with catastrophic consequences.

The other problem that exists is that the number of available vaccines has almost been depleted and hence, even if people want to be vaccinated, they cannot easily find the vaccine. It would seem that Japan was taken unawares of the potential outbreak.

The current epidemic shows how important vaccination is to prevent disease. Side effects from vaccination, albeit rare, do not outweigh the benefit of life saving immunity. The previous concerns about Crohn's disease and autism from combined MMR vaccination have never been proved and when this similar problem occurred in the UK, the Government at that time, did everything possible to ensure that vaccination was maintained to a high level. However, vaccination levels also dropped, as in Japan, and new cases of Measles began to occur.

However, the outbreak in Japan may be more extensive than that seen in the UK and there may be more cases of measles yet to occur. Case fatalities will occur as it is inevitable with this infection.

I only hope that the correct preventions are used by health care providers to ensure that spread is restricted as much as possible and that correct quarantine procedures are adhered to. I hope that in the future Japan will see a higher level of vaccine uptake to ensure that an outbreak of measles never happens again and this disease become a medical relic in the textbooks like Smallpox !

Busy, Busy Busy

This week has seen Dr Aoki begin his lectures for the new first year doctors. Many of the junior doctors turned up with their copy of Dr Aoki's book and he was happy to answer questions for the residents during and following the lecture.

Here are some photos below:







This week also saw me invited to conduct Bedside Teaching Rounds in the ER department. The residents, myself and Dr O. saw a great case that turned out to be a different diagnosis to what I had initially expected and putting together the history, physical examination and laboratory data provided the clues to the probable diagnosis.

I will therefore be teaching in both General Internal Medicine and Emergency Medicine in the foreseeable future.

I have also had my Kyorin medical student shadow me for the last 3 weeks and I think his eyes have been opened as to how a good history and physical examination are sometimes better than machines ! :)

I have noticed both from medical students and junior doctors that their knowledge of drugs including generic names, mode of action, side effects and interactions are not as good as they should be. This is a very important part of being a practising physician and although, as i am informed, it is not an important part for passing the final examination, it is however important for treating patients safely and effectively.

For example, in a recent case, a patient was admitted after overdosing on anti-epileptic agents, neuroleptic agents and tricyclic anti-depressants. After checking the drug interactions, which had not been done, we found that the combination proved to be a potentially lethal cocktail which could induce a Long QT interval and hence, Torsade de Pointes. After reviewing the ECG it indeed showed a prolonged QT of 458 msec !!!!! Hence, if the patient had developed a tachyarrhythmia or VF, the therapy would have been Magnesium rather than other anti-arrhythmic drugs which is a very important point.

Unfortunately, there is no guarantee that the previous physicians checked about the interactions of these drugs which brings me back to the emphasis on the proper education of pharmacology.

It is very, very important to know details about drugs and especially about Generic names and junior doctors by just re-writing the drugs on admission to hospital or on discharge without knowing why they were prescribed or checking side-effects / interactions is not sufficient and this needs to change.

There are some very good British and American pharmacology textbooks and I would strongly suggests that medical students and junior doctors obtain such reading material to improve upon where they may have deficiencies in their knowledge on pharmacology.

Next week sees the Famous Professor Stein visit from the USA and it should be a very busy week for me again and most enjoyable too!!

Have a great weekend.

Never Move An Unstable Patient

This story is anonymised and is from the UK.

A very sick patient who was admitted following an out of hospital cardiac arrest with a substantial time without effective CPR before arrival of paramedics, rendering the patient with likely global hypoxic-ischaemic brain damage.

The admission ECG showed diffuse anterior ST depression and with resolution there was persistent ST change consistent with a N0n-ST Elevation MI (NSTEMI) which is an acute coronary syndrome (ACS).

Following admission, the patient developed recurrent generalised seizures requiring intubation to protect the airway.

The CT head scan showed an old infarct and frontal cerebral wasting but no SAH or intracerebral haemorrhage.

Diazepam was given followed by phenytoin rapid infusion, but both failed to curtail the seizure activity.

There were recurrent Jacksonian seizures every 2-3 minutes and lasting up to one minute, and the junior doctor was not completely certain how to proceed from there.

However, because a bed was then ready on another ward, the staff were hastily collecting the notes to transfer the patient despite recurrent seizures being present. Despite a protected airway, this did not prevent the patient from developing possible complications of seizures such as recurrence of a cardiorespiratory arrest, intracerebral haemorrhage etc...

The junior doctor was advised that a patient must be stable prior to being moved and when eventually moved, they should be accompanied by doctors and nurses who can perform CPR and they should have the correct resuscitation equipment with them in the case that the patient was to have a further cardiorespiratory arrest en route.

Sometimes, the eagerness to clear a bed space and move the patient from an emergency department to reduce nursing work can actually place the patient in a dangerous predicament.

One must always remember that the patient comes first.

The ultimate responsibility lies with the doctor overseeing the patient's care and it is the duty of the doctor to ensure that the patient is stable before moving them.

In this case, the junior doctor gave an infusion of midazolam which terminated the recurrent generalised seizures providing a hiatus of stability thereby allowing the patient to be moved safely.

This case demonstrates the importance of stabilising patients and although each situation is different, the general principle applies.

There are sometimes exceptions to the rule such as the patients with severe haemorrhage who require immediate surgery and patients in an unstable environment e.g. war zone.

However, patients with upper GI bleeding who require an emergency gastroscopy who are haemodynamically unstable should not be moved and such patients should have this examination with gastroscope done in the emergency room.

As a doctor, you are responsible for the patient and other staff rely on you to make a plan of action. It is your responsibility to ensure that the patients can be stabilised and if you need help then ask your senior to come.

Never be pressurised to move an unstable patient when you know it is the wrong thing to do.

Sometimes standing your ground and reasoning the point with staff who do not fully appreciate the problem can save your patient from complications.

Rare as Hens Teeth

This patient had a diagnosis of streptococcal pneumonia on admission .

She typically had reactivation of Herpes affecting her upper right lip area.

However, she complained of a painful tongue after several days in hospital and the next day she developed a rash on her tongue.

A dermatologist was consulted and an odd diagnosis of amyloidosis was considered.

However, the history was not consistent with amyloidosis as it was too acute.

Moreover, the examination revealed separate, small vesicles on the tongue, predominantly right sided with sparing of the posterior 1/3 of the tongue and left lateral border.

The right inner lip mucosa also showed a shallow, white ulcer.



The diagnosis consistent with the preceding history would be one of Lingual Herpes Simplex infection from likely reactivation or even Varicella Zoster eruption.

HSV and VZV can be reactivated by streptococcus pneumoniae infection, fever, sunlight, stress and during menstruation in females.

The treatment involves oral aciclovir, usually at a dose of 200mg 5 x per day, or if severe then intravenous at 5mg/kg/day.

Oropharyngeal HSV is very infectious and health care workers should wear gloves if they are likely to come in contact with the oral secretions.

Labial HSV (cold sores) are very common and although reactivation can occur anywhere such as in the oesophagus in tube feed patients, pubic region (HSV2 > HSV1) etc, but to see it occur on the tongue is most unusual.

One has to consider underlying causes of immunodeficiency in such patients such as HIV or haematological malignancy being possible underlying diseases.

The posterior 1/3rd of the tongue is unaffected in this patient because the nerve supply to that area is different, being the Glossopharyngeal Nerve (IX). The left border of the tongue was equally unaffected as the HSV did not reactivate along the nerve supplying that region.

The central tongue is affected in this patient showing that the right nerve supply also crosses the midline to supply a large area of the contralateral tongue.

Social History

Dear Bloggers

I was asked just today what was the purpose is of a social history.

Well, I had taken for granted that social history was well known and for what purposes.

Having thought in great detail I was able to provide a very detailed number of reasons, and they can sometimes be more important than the reason for admitting the patient to hospital.

For example, when a patient is admitted to hospital, the doctor must start planning for their discharge and mentally estimate when that will be so that a timely exit from hospital can be arranged.

However, the social situation at home must be established to understand if the home dynamics are safe. For example, a patient with COPD who sleeps upstairs may no longer be able to use the steps and therefore, modifications may need to be made at home. The same goes for patients with recurrent falls who may need hand railings placed in dangerous areas at home.

In the UK, discharges home are sometimes delayed not because of the patient condition, but because the doctors failed to appreciate that they had to plan the discharge by arranging for a physiotherapist to retrain the patient and for a home assessment to be made to ensure safety.

Moreover, social history examines the home dynamics such as relationships, financial funding, ability to cook, clean, wash and doing the daily activities such as shopping. Is the patient the carer for their ill relative and if so, by entering the hospital, who will look after the relative?? The same goes for children when a parent is admitted to hospital.

Without a social history, no idea can be understood of the family situation and therefore, very important matters may be missed.

Funding can be a big problem for the elderly who have little savings and for those families with low incomes. In the UK, with the Welfare State, funding can be obtained to help pay for expenses of home modification, providing home care such as washing, cleaning and bathing plus if need be, full time nursing care facilities.

The situation in Japan is somewhat different from my experiences.

Other important matters identifiable from a social history include where the patient lives? In a house, an apartment. Are there stairs that need to be climbed? Can the patient climb them or do they need to stop? Does the elevator work?

Is the patient in an industrial area ? Have they ever been exposed to dangerous chemicals / materials e.g. asbestos

Does the patient have animals at home? Was the chest disease caused by the pet bird in the cage at home??

All these are part of the social history or they can also be incorporated as direct questions in the history of the presenting /chief complaint.

This provides the doctor with very interesting elements of the patients life that may throw up unforeseen risk factors not previously appreciated.

Secondly, as I have already alluded to, it provides the doctors and social workers the ability to work towards a home package that can be set in motion upon discharge home of the patient if such a package is required.

Finally, in fact alcohol and tobacco are NOT part of the social history and I always find that this is the only thing that is mentioned when the words social history are uttered. Tobacco and alcohol are HABITS.

I think from the above information it can be readily appreciated that social history is a detailed evaluation of the patient's life before entering the hospital and it should never be forgotten to be asked in detail.

I hope this gives you something to consider.

All the best.

Golden Week Mayhem and Training Opportunites

Dear Readers

Since returning from Golden Week, I have been extremely busy with my duties and I am afraid I have neglected my blog.

I am hoping to bring some interesting cases or discussions to this blog later this week.

I now have been joined by a medical student from Kyorin Medical School who wants to learn about history and physical, and as he termed it, I am his "Case Study!"

As I have mentioned previously, I am happy for medical students and / or doctors to come to this institution for short or longer periods to take part in externships if they wish to learn from me or to learn internal medicine from our other doctors.

If you are also interested in such study opportunities, then please join up to gmail and drop me a line on this blog and I can then contact you directly via your gmail email address.

Of course, your comments with not be published and will be kept confidential.

Abuse Of My Blog

Dear Readers

I am occassionally getting anonymous comments that are an abuse of this blog and as moderator, I must choose whether such comments should be published.

In the main, most polite and reasonable comments are published.

I should stipulate that only clinically related comments in respect of this site will be published and not advertisements for peoples books!!

However, I feel it is now necessary to restrict all comments by asking all those who wish to leave a comment to do so by signing into Gmail.

I trust that you will understand reasons for this decision as I hope it will ensure that the quality of legitimate comments is maintained.

WOW!!! What A Case For Differential Diagnosis !!!!

I have another GREAT CASE here which comes from a distant hospital.

The case is anonymised as always.

The patient was an elderly female who was referred to the hospital after an emergency call out for Chest Pain.

The patient had awoken at 10:30pm when she got up to visit the toilet. She developed sudden onset of chest pain that was severe and continuous and sharp in nature. The pain was also described as radiating to the patient's back. After 1.5 hours the patient arrived at the hospital and quickly underwent emergency examination.

Further history was taken and it became apparent that the pain was situated to the left of the epigastrium (so called the left hypochondrium). It was unrelated to movement or respiration. The patient denied being breathless, and it was apparent that this was the first time this pain had occurred. There was no associated cough, sputum, haemoptysis, radiation to the neck/jaw/arms, no nausea, no vomiting, no report of recent tarry stools (malaena). There was no history of GERD and no history of flatulence. The patient denied weight loss, constipation or diarrhoea. There was no description that the radiating pain was tearing or not.

The only previous medical history was of hypertension which the patient had for 10 years. She had decided to stop her anti-hypertensive medications 3 months previously without medical advice.

The patient smoked 60 cigarettes per day and liked to drink sake.

On examination, the patient was afebrile, BP 200/120, heart rate of 68/min, respiration rate was 16/min with an Sp2 of 96% on room air.

Physical examination was unrevealing except for signs of liver disease (palmar erythema and spider naevae on the upper chest).

Chest and abdomen revealed no localising signs for the cause of the pain and the abdomen was not distended and apparently non-tender.

However, the ECG revealed ST depression and T wave inversion in V5 and V6 suggestive of ischaemia.

Blood results revealed a normal initial CPK 86 (61-265) but the CK-MB was raised 17 (4-16) but Troponin T was <0.05.>3.3, AST 75 (13-37), gamma GT 467 (12-49), CRP 1.13 (<0.30) style="font-weight: bold;">pH 7.485, pCO2 38.5, PO2 64.9 (74-108), HCO3 29 (21-29), BE 6.2.

The top differential diagnoses included:

• Acute MI
• Pulmonary embolism
  
• Unstable Angina
• Aortic Dissection

The chest roentogen looked normal.

The CT abdomen was revealing as it showed a very abnormal aorta. See below:

On seeing the patient by a senior doctor, it became apparent that the history was slightly different. In fact, the patient had described ABDOMINAL PAIN, rather than chest pain as relayed by the paramedics to the hospital staff, and it was described as 'PULSATILE', not sharp, meaning for every heart beat the pain recurred i.e. pulses of pain. It was also asked whether the patient had been experiencing back pains in the SAME LOCATION sometime before the severe pain to which the answer was YES.

The patient denied symptoms of intermittent claudication (ASO).

The patient had undergone emergency surgery and the diagnosis was described as a pre-rupture of an Abdominal Aortic Aneurysm (AAA). The surgeon described it as pre-rupture as there was no bleeding into the retroperitoneal space. The location was infrarenal and involved the iliac arteries as well. The patient had a graft placed and achieved good haemostasis and pulses to both limbs.

However, it was also of concern about the aorta higher up in the patient's chest as on initial inspection of the Contrast CT, it looked like there was a proximal dissection that had migrated to the lower abdominal aorta. On more detailed inspection it appeared that there were two separate vascular luminal dissections, one in the thorax and one in the abdomen, the latter being the bigger of the two.

It was of concern that the more proximal dissection had been overlooked in the emergency situation because of the large possible impending rupture of the large abdominal aortic aneurysm.

Hence, it was requested that the doctors have the radiological films formally reviewed by a Radiologist and the result is below:

Thoracic lesion: dissecting aortic aneurysm (thrombus closing type) is seen from the bifurcation of the left subclavian artery to the upper surface of the diaphragm .

Lower abdominal dissecting aortic aneurysm (New pathologic lesion) is seen. At least TWO dissected cavities are overlapped. They are not enhanced, but the density is comparatively high.

Upper abdominal lesion, there is no dissected area but some enlarged lesion can be seen.

Radiology confirmed a total of THREE dissecting aneurysms in this patient.

This is an extremely interesting case, and it is rare to see three dissections in a single patient.

Obviously, the surgeons were concerned about impending aortic rupture as a result of continuing oozing of blood into the aortic wall, and hence, the patient underwent emergency surgery, but in the main, uncomplicated distal dissecting aortic aneurysms are treated conservatively with blood pressure control.

The more proximal dissections involving the aortic root and arch DO require surgical intervention on an emergency basis as complications such as stroke, aortic insufficiency, coronary ischaemia, tamponade and haemothorax (left sided) can occur, all of which may be fatal.

However, by far the commonest cause of dissections is vascular injury by high blood pressure and in the main, hypertension is associated with distal dissections rather than proximal ones, as in this case.

Other causes include:

• Trauma/iatrogenic- cardiological investigations / procedures e.g. coronary angiography, CABG, Previous aortic valve replacement
  

• Inflammatory disease causing vasculitis e.g. syphilitic aortitis, Takayasu's arteritis, RA etc
• Collagen Disease: Marfan's Syndrome (approx 50% cases of dissection aged <40 style="font-weight: bold;">Ehlers-Danlos syndrome, annuloaortic ectasia
• Congenital: Biscupid aortic valve- dissection always involves the ascending aorta, Coarctation of the Aorta, Turner's Syndrome (associated with coarctation)
• Drugs: Cocaine; transient rise in blood pressure from surge in catecholamines
  

Finally, to recap, most dissections occur in the 60-80 age group and more in males than females.

The pain of dissection is SEVERE and can be Sharp or classically 'tearing' in nature in the rear of the chest or produce back pain. Pain can also be in the anterior chest. The pain can radiate to the chest or abdomen.

Proximal dissections are more associated with chest pain and distal dissections with abdominal and back pain respectively as a general rule.

Examination should include examining all the peripheral pulses. Typically, if dissection is present one may see a 20mmHg difference in blood pressure in the upper limbs.

Examine the JVP, as may be elevated in Tamponade.

Examine for Pulsus Paradoxus-- drop of >10mmHg BP during inspiration; associated with Tamponade.

Listen for reduced heart sounds and listen for the diastolic murmur of Aortic Regurgitation (proximal dissection).

Percuss the chest for effusion (might be a haemothorax)-- however, patients typically will have internally exsanguinated if this is present.

Listen for bruits or absence of bowel sounds-- suggestive of vascular compromise.

Check neurological examination if evidence of weakness as it implies vascular occlusion by the migrating dissection (proximal dissections).

ECG can be normal, especially in Distal dissections, but in proximal type, it may cause coronary ischaemia.

Chest Xray can be normal in dissection and does not exclude the diagnosis.

Once dissection has been considered, it must be excluded, and scanning modalities such as CT are quick and provide a degree of accuracy to reach the diagnosis.

Finally, well done to the doctors who got the diagnosis and treated the patient quickly !!!

Have a Great Golden Week!!!!!!!!!

UpToDate Keeping Me UpToDate

Dear Readers

It would seem that although I am reading UpToDate for some of the best EMB and references around, UpToDate USA and Japan are reading this blog too!!

I recently had contact from their Japanese Office Director, and I very much welcome the review of this blogsite as they will only find complimentary words for such a great product.

I have been kindly advised that the UpToDate software should work on Japanese Windows Pocket PCs, for example, the Willcom PPC made by Sharp.

If any of you have UTD which has been having any problems on your Japanese PPC then please contact the UTD Japan Office and I would hope that they will be able to sort them out as soon as possible :)

UpToDate, Inc. Japan Office
Sumitomo Shinbashi Bldg.7F
1-8-3 Shinbashi Minato-ku
Tokyo 105-0004
Japan
japan@uptodate.com
Tel 81-3-3572-5002
Fax 81-3-3572-5003

Best wishes.............

Sherlock Nose

This case has been anonymised for patient confidentiality.

An elderly patient was originally admitted several weeks ago with a fever and after investigations, a urinary tract infection was diagnosed. The urine grew a drug resistant Proteus mirabilis that was probably acquired at the nursing home where the patient normally resides.

It was not initially know what the organism was and so a broad spectrum antibiotic cover was used (cetriaxone).

Initially, the patient made good progress until one week ago when fever recurred. After work-up, it was established that the patient had acquired a hospital infection from Pseudomonas aeruginosa and Group B streptococcus, with infiltration being noted at the lingula of the left upper lobe. Quite rightly, antibiotics were changed and the patient was started on piperacillin and tobramycin to which the organisms were sensitive.


However, the patient continued to deteriorate with no change in the spiking fever and with raised white cells and CRP.

A senior doctor was asked to consult for the patient because despite good antibiotic cover for the identified organisms, the chest xray was worsening.

Before seeing the patient the senior doctor was shown a recent Xray and it revealed a well circumscribed lesion in the right upper zone, not typical of a pneumonia.

Most importantly, going to see the patient gave a potential diagnosis.

On entering behind the curtain there was a very strong smell of anaerobic organisms, a similar smell of most hospital laboratories !! Knowing that the patient was diabetic, the feet were initially examined for infected diabetic foot ulcers. However, although there was some pressure areas, there was no ulceration.

The feet were smelt closely, but no smell was emminating from them. The smell was followed upwards and it became extremely strong from the patients MOUTH !!!!

A torch was shon in the mouth and it revealed a green exudate on the top of the right gum area consistent with an anaerobic infection. This patient's mouth was also extremely dry because of mouth breathing only.

Listening to the chest, there were reduced breath sounds at the right upper zone and crackles at the right base and left mid zone consistent with some of the Xray findings.

At this point, the diagnosis pointing to being a Lung Abscess from anaerobic infection until proven otherwise with possible aspiration pneumonia at the right base as well, although the Xray does not show obvious right basal changes, and hence, this shows just how important good clinical examination is.



It was advised that the patient see an oral specialist to ascertain if there was any evidence of oral abscess and to detail the dentition.

Moroever, this patient underwent CT scanning and it revealed an unusual but well circumscribed pneumonia rather than an abscess.

However, with an obvious oral anaerobic infection plus evidence of oral aspiration in addition to markers of infection, being unresponsive to aerobic cover antibiotic therapy and a well circumscribed right upper lobe lesion, the differential diagnosis should always include an anaerobic abscess.

The patient responded well to piperacillin and clindamycin and the infection resolved rapidly.

However, the oral anaerobic infection still persisted despite antibiotic therapy and good mouth cleansing.

The patient later developed a further pneumonia and this time it was diagnosed as a severe fungal pneumonia which was refractory to therapy and this was an indicator of severely impaired immunity.

The commonest cause of lung abscess is from anaerobic organisms and often the patient has poor dentition and aspirates the bacterial during respiration to predispose to the infection.

Moreover, this patient was immunocompromised due to diabetes and in addition, the patient had already had two other infections in recent weeks. Most significantly, the patient had Parkinson's disease and Lewy Body Dementia and had previously aspirated and thus, he was always at significant risk for this problem.

Of course, in this case, the presence of Psuedomonas may have been the cause of the abscess but certainly coverage of anaerobic organisms was warranted here.

Remember to always look at the FEVER CHART and a good indication of an abscess is the classical Spiking Fever. Try and keep things simple, like trusting your sense of smell, and often the diagnosis makes itself known to the doctor.

Hence, all that was needed was a nose, a stethoscope, an Xray and of course, Sherlock Holmes.

Today's story is thus Sherlock Nose !!

Have a great Golden Week !!!!

Having passed this case on to Professor Tierney he made a number of observations:

Firstly, only 60% of bacteroides produce the typical anaerobic smell and hence, the absence of such as smell does not exclude the diagnosis of an anaerobic infection.

Secondly, in the patient without teeth, the presence of a lung abscess is lung cancer until proven otherwise. Original quote was: A lung abscess without teeth is cancer of the lung until proven otherwise- Prof Tierney

Thirdly, lung abscess treatment should include rigid bronchoscopic drainage with antibiotic therapy.

Many Thanks to Professor Tierney on these points, and I am sure the Blog Readers fully appreciate his expert contribution.

TB Alive and Well In Japan

Todays blog is just a quick reminder to ALL doctors to consider Tuberculosis infection in any patient of any age presenting with chest symptoms.

Recently, a young patient presented to a northern Japanese hospital with a two week history of cough, sputum and a mild fever.

She had been seen 3 years previously with a similar episode and Mycoplasma infection had been diagnosed and subsequently treated.

She had no current risk factors for tuberculosis and denied risky sexual exposures. Her grandmother had had TB earlier in her life.

The patient was otherwise healthy and was taking no medications.

Her examination was otherwise unrevealing including chest examination.

The clinic doctor considered this to be an atypical pneumonia due to the history of the current illness and previous atypical pneumonia.

However, the chest radiograph revealed a right apical lesion which was highly suspicious of Tuberculosis.

Sputum examination with the Ziel-Nielson stain revealed two acid-fast bacilli.

Hence, these results were very suggestive of active tuberculosis primary infection.

Interestingly, she had only a mild fever and cough but none of the typical features in her history such as:

• night sweats
• weight loss
• chronic cough
• bloody sputum

Of course, it is useful to obtain a formal bacteriological diagnosis through growth on Lowenstein-Jensson media, but this should never delay treatment for TB.

Always think TB !!

Do you have any current figures for the background prevalence of TB in Japan and know why Japan has such levels of TB?? If you know, then please let us all know by leaving a message on my blog!

Wow What A Case!!!!

This anonymised case concerns a middle-aged male patient who presented to another hospital with a five day history of:

• Pleuritic chest pain
• Cough
• Fever

The pleuritic chest pain was associated with breathing and was sharp in nature. In did not occur on moving. There was no central cardiac chest pain of ischaemic origin. The pain was also described to be in his back but it was not tearing in nature.

The cough was non-productive and intermittent.

The fever was low grade in its characteristic. He denied rigors and sweats.

The patient had been initially seen five days previously at our ER department and it had been considered that he had pleurisy and he was given acetaminophen and allowed home. However, these symptoms got worse and the patient was seen at the outpatients with the new symptom of Haematuria which was non-painful with there being no urological symptoms.

On examination she was stable but appeared in pain.

Pulse was 90/min, JVP was raised, BP normotensive but there was a drop of approximately 10mmHg in blood pressure during respiration. Temp 38 degrees and RR was 14/min. Sats 89% on room air.

Lymph nodes were not paplable.

The patient had dullness at both bases. With the patient sat forwards there was a loud sharp murmur in the tricuspid area on Inspiration which disappeared on Expiration. On lying flat, there were some audible crackles over the lower left parasternal border.

Whereas the initial chest Xray had been normal, then second one, just a few days later, revealed bilateral mild effusions and a globular heart. Her initial ECG when performed in the ER was normal, but the second revealed 1mm ST elevation in V5 and V6 with no reciprocal changes and no ST saddling or P-R depression. The voltage was also reduced.

Bloods revealed a raised white cell count, CRP 3o, slightly raised bilirubin but normal AST and ALT. ALP was slightly raised but no isoenzyme was taken. The haemoglobin was within normal limits. Renal function was normal. CK and CK-MB were not raised.

The suspected diagnosis was an acute pericarditis.

A cardiac echo was performed which revealed a rim of pericardial fluid with there being no RV collapse. There was no evidence of a vegetation either.

CT scan was performed which revealed the same pericardial effusion plus bibasal pleural effusions.

It was suggested that the effusions should be examined and the fluid obtained was yellow 'straw' coloured but slightly turbid. The white cell count was >3,000 and the pH 7.3. The sample was sent for Rheumatoid factor, culture, LDH, Glucose and TB examination.

Possible causes of acute pericarditis include:

Drugs and Toxins

• procainamide
• hydralazine
• phenytoin
• isoniazid
  

(Produce a Lupus-Like Syndrome)

Infection

• Viral: Echovirus, Coxsackie

• Bacterial: Streptococcus spp (particularly pneumococcus), Staphylococcus, Mycoplasma, TB, Haemophilus
• Fungus: Histoplasmosis, candida, aspergillus, coccidioides
  

Trauma

• Recent cardiac surgery / intervention e.g PTCA

Inflammatory

• Post-AMI
• Dressler's Syndrome
• Post-Radiation therapy
• SLE, RA, MCTD, systemic scleorsis
  

Neoplasia

• Infiltrative neoplastic diseases e.g. primary or secondary tumors
• Lymphoma /Leukaemia

Metabolic

• Uraemia, Hypothyroidism
  

Interpretation

Well, this is a very interesting case as the patient had clearly developed a percarditis and a rapidly enlarging effusion with signs of tamponade e.g. drop in BP and raised JVP. The murmur on sitting which disappeared on lying may be due to haemodynamic changes with venous flow changes. The typical scratching pericardial rub is also usually found with the patient sitting forwards BUT it is classically heard on Expiration not Inspiration.

The rapidly enlarging pericardial effusion with ensuing tamponade should prompt for the patient to be considered for pericardiocentesis. In this case, the pericardial effusion stopped enlarging and thus far, he has avoided requiring this procedure.

In respect of the haematuria and raised bilirubin level of which both direct and indirect bilirubin were raised, may be consistent with an intravascular haemolysis although typically the indirect level is raised.

Consideration should be given to Mycoplasma as the cause, as this can produce Cold Haemagglutinins which can produce such manifestations of haematuria. However, patients tend to develop a low grade anaemia which this patient did not have. Moreover, one should not rule out infective endocarditis here either.

Due to the rapidity of her symptoms, TB was considered unlikely, but it was still tested for.

There were two considerations here:

• Pain relief
• Anti-microbial therapy

This patient had been taking long-term aspirin although she had no cardiovascular history. One concern was of a haemopericardium from a haemorrhagic pericarditis. The usual therapy for pericarditic pain is NSAID therapy, but all anticoagulants should be avoided if there a rapidly enlarging pericardial effusion.

Hence, one suggestion was to use opioid pain relief instead. However, haemorrhagic transformation of pericardial effusion is a theoretical risk. The patient did eventually receive NSAID therapy.

Secondly, despite the vast majority of cases of acute pericarditis revealing a viral origin, it still needed to be considered as a bacterial cause especially as the pleural fluid contained such a high amount of white cells.

Hence, it was suggested adding a third generation cephalosporin (Ceftriaxone) which would cover the vast majority of organisms explained above plus continuing the clarithromycin to cover mycoplasma.

Blood cultures revealed Gram Positive Cocci and later identified as a fully sensitive streptococcus pneumoniae organism.

Acute Bacterial Pericarditis is the likely diagnosis here although a Purulent Pericarditis had not been confirmed as a pericardiocentesis has not been performed. For that diagnosis a pericardial effusion should either be macroscopically or microscopically purulent. However, some infections such as viral and bacterial, particularly Mycoplasma hominis, do not produce a purulent effusion (UptoDate 15.1)

Infectious aetiologies resulting in a purulent pericarditis include pneumonia, endocarditis or even meningitis.

Ultimately, if this patient's pericardial effusion had failed to improve and / or her clinical condition worsens, then she would have needed a formal pericardiocentesis which has the advantage of being both therapeutic and diagnostic.

Typically, analysis of fluid in purulent pericarditis shows cells ranging from 6,000 to 250,000 per microL, low glucose of <35mg/dl style="font-weight: bold; font-style: italic;">UpToDate 15.1)

Antibiotic regimens depend on local resistance levels, the immunocompetency of the patient and whether the patient has developed the problem in the community or in hospital.

Most regimens include either a 3rd or 4th Generation cephalosporins and Vancomycin needs to be considered in view of the problems of MRSA in this era and this was later recommended in this patient.

Non- infectious aetiologies can also present with a purulent pericardial effusion such as malignancy, uraemia and recent surgery.

Finally, a transthoracic echocardiogram may miss an endocarditis and hence, a trans-oesophageal echo which has a higher yield would be advisable.

However, the modified Duke's Criteria does not require for a vegetation to be present to make the diagnosis of endocarditis, but please refer to my earlier blog on endocarditis for those details.

For a fuller explanation please see UpToDate 15.1.

The patient made an uneventful recovery and was left with a mild pericardial rub and no chest pain.

Rheumatological Case- V. Interesting

I have a very interesting rheumatological patient to tell you about.

Firstly, as always, the patient has been anonymised to safe guard confidentiality.

The patient was a middle-aged female and who presented to another hospital with a history of muscle pain in the proximal lower limbs, some upper limb-shoulder discomfort and pain in the occipital-neck area. The patient also had a low grade fever. The patient complained of no eye problem, no temporal tenderness, no jaw or tongue claudication (symptoms for Giant Cell Arteritis). The patient had no symptoms suggestive of infection. Patient had a normal appetite but had complained of some weight loss. There was no complaint of changes in bowel habit.

The was no joint pain or swelling. No skin rashes. No respiratory symptoms.

The patient had no other significant history and was taking no regular medications.
The patient had occasional alcohol and cigarettes.

Physical examination revealed a low-grade fever. Vital signs were otherwise normal. Eyes revealed a slight purple discolouration to the upper eye-lids.

The was no lymphadenopathy and cardiovascular, respiratory and abdominal examinations were normal.

Occipital tenderness was present one week previously but only seemed to be a problem when the fever was present. There was no temporal artery tenderness.

Neurological examination revealed proximal muscle wasting, some lower limb muscle discomfort on palpation. Power and Reflexes were maintained.

Clinical Impression from history and examination:

• Polymalgia Rheumatica (PMR)
  
• Possible Dermatomyositis

However, ESR >100 and CK was low NOT RAISED. Auto-antibody tests were all NORMAL although anti-JO-1 antibody is still awaited.

In view of the history, physical and blood results, the diagnosis is very likely to be PMR.

However, infection needed to be ruled out. CXR was normal. Urine examination was normal. Blood cultures were normal.

Cardiac ECHO was normal. CT scan of abdomen was again normal.

Despite this data, the doctors were advised to start antibiotic therapy with there being no evidence of a bacterial infection and a negative infection screen.

Following this therapy, steroids were advised to be commenced.

It was considered that this diagnosis was PMR in view of the history, symptoms, ESR >100 and with a negative auto-antibody and infection screen.

The concern here was the occipital pain experienced by this patient. This could represent Giant Cell Arteritis which has a significant overlap association with PMR (approx 25-30%). Patients with GCA are at risk of visual loss and arterial infarcts and need to be treated on an expedited basis with steroids and aspirin. Usually, an arterial biopsy is taken to confirm the diagnosis but even if the biopsy appears normal the diagnosis of GCA cannot be excluded as vessel changes can be multifocal.

Patients with PMR typically experience proximal muscles pain and weakness, but on physical examination, the power appears almost normal. The CK is normal although the ALP may be raised due to peri-portal inflammation. The ESR is usually high but even normal ESR can be consistent with PMR.

Dermatomyositis on the other hand can present with weakness, wasting but the CK is high as is anti-Jo-1 antibody. Other manifestations include purple skin changes around the eyes, on the dorsum of the fingers, elbows etc and are Heliotrope as so named. Patients may also have fibrotic lung changes and there is an association with malignancy (10% in patients aged >40yrs) although this is disputed. Such malignancy tends to be gastrointestinal in origin.

In this case, it was advised that the steroids be started on an expedited basis and one would have hopefully seen a response with 48 hours.

Steroids usually need to be continued for about 2 years and they are slowly tapered over that time mindful of the patient's symptoms and ESR.

This patient's blood sugars would also need to be monitored as steroids can induced Type2 Diabetes mellitus due to their multiple blood glucose elevating effects and insulin resistance.

In the long term this patient would have needed to have bone density scanning to look for osteoporosis with the treatment there being once weekly alendronate (fosamax).

Consideration should have been given to using a Proton Pump Inhibitor to reduce the risk of upper gastrointestinal bleeding especially as the patient would have been potentially taking several problematic gastric agents in the future including steroids, aspirin and fosamax.

Ways to Improve Treatment in Emergencies

There have been a few cases I would briefly like to discuss where I consider the use of evidence based medicine and protocol guidance could have made a difference.

A young male was seen with an influenzal illness and then wheezing. The patient had a back ground of severe asthma having been previously ventilated. It would appear that this patient continued to smoke cigarettes and took aminophylline and inhaled therapy, although at the time of admission, the inhaler therapy was unknown.

The patient had severe-life threatening asthma-- he could not speak, respiratory rate was 25, pulse 120 although BP was high rather than low. The patient was using accessory muscles and had severe diffuse wheeze.

ABG- revealed a respiratory acidosis and hypoxaemia, and it was decided to intubate and ventilate the patient under propofol sedation.

The problem began a few days earlier when he was seen at a clinic and where he was given iv steroids and sent home. The next day he went to another hospital and was given aminophylline and steroids and discharged after just 24 hours. He worsened at his home which precipitated his admission to a different hospital.

Firstly, the only safe way to discharge patient is to know that their Peak Flow measurements are stable and not less than 25% of the normal predicted value for the patient's age and sex. If Peak Flow is not measured, the doctor has no formal means of assessing the severity of asthma and whether it is getting better or worse. Asthma patients can only be switched to inhalers once Peak Flow is stable and they still need to be hospitalised for at least another 24 hours and be stable on inhaler therapy before allowed to go home. Moreover, patients usually need several days of steroid therapy orally to reduce bronchial oedema associated with asthma and this cannot be cured by a 'one-off' shot of methylprednisolone.

Secondly, he was quite rightly intubated and ventilated, but when the patient was seen by a senior doctor, although the ABG had significantly improved, the patient was poorly sedated, respiratory rate was higher at 32/min, pulse was 150 (sinus tachycardia) and the patient had severe wheeze, on the left more than the right.

Clearly the therapy needed maximisation and this was a case of severe-life threatening asthma as a result of a viral infection and smoking.

The advice obtained, based on evidence and guidance from UpToDate 15.1 and British Thoracic Guidelines was to:

• Add beta-stimulant
  
• Provide a high dose of steroid using a traditional steroid for asthma treatment such as methylprednisolone or hydrocortisone; not betamethasone that had been given.
  
• Magnesium sulphate therapy (used to stabilise histamine containing cells)
• Paralyze and formal mechanical ventilation (with a general anaesthetic) as this would reduce the work of breathing, and GA can have a bronchodilator effect e.g. isofluorane. I have also seen this effected with high dose propofol under mechanical ventilation.
  

In the UK, where intravenous salbutamol is available, I would advocate its use in this severe form of asthma and in addition, the use of nebulised atrovent with salbutamol (beta-stimulant) which together have a better effect on control of asthma than beta-stimulant alone. As I understand it, and cannot quite fathom why, ipratropium (atrovent) is not available in nebulised form in Japan, when this is a life-saving and relatively innocuous therapy useful in asthma and COPD.

I have talked of asthma before on this blog, but I have found that its management in Japan is not in keeping with other international guidance and there needs to be standardisation for provision of effective evidence based therapy.

Peak Flow measurement is extremely important and this patient could have possibly avoided this episode if he had been keep in the previous hospital on appropriate therapies and under close observation.

If you wish to know more, please check the British Thoracic Guidelines for asthma plus UpToDate 15.1.

Another problem I have encountered is the wrongful belief that it is correct not to treat atrial fibrillation and by treating the underlying cause it will somehow spontaneously resolve itself.

This kind of advice is NOT consistent with international therapy for AF.

Arrhythmias are not a normal occurrence and AF amongst other rhythm disturbances, can precipitate coronary ischaemia and make heart failure or underlying ischaemia far worse. Moreover, the longer that AF is left untreated, the more difficult it becomes to cardiovert the patient. Elderly patients who are affected by AF the most, may have other underlying diseases and a drop in perfusion due to fast AF can cause compromise to other organs.

Hence, it is important to treat AF promptly and not leave it to somehow get better by itself.

Dehydration in itself, is not an established cause of AF.

Patients should also receive some form of anticoagulation, unless contraindicated, to reduce the risk of stroke events which are approximately 2% per year but higher in cases where there is underlying mitral stenosis.

Fast AF with low BP should be treated by DC Cardioversion but if normotensive, it can be slowed with effective drugs such as Amiodarone, beta-blockers or Ca channel blockers or Class 1c drugs such as flecainide or propafenone acutely.

If there is heart failure and if it is not safe to give beta-blockers or calcium channel blockers e.g. with a low ejection fraction, then amiodarone or digoxin can be given.

Flecainide cannot be given if there is underlying ischaemic heart disease as it can be made worse by this drug and hence, is probably inadvisable in most instances as one of the commonest causes of chronic AF is ischaemic heart disease.

Flecainide and propafenone should not be given chronically as ironically they increase the risk of death from dysrrhythmias.

Even mild to moderate AF should be treated to slow the rate to less than 100 as the ventricles have more time to fill and hence, the ejection fraction and cardiac output can improve.

Of course, trying to establish the underlying cause of AF and treating that may help the AF to resolve e.g. thyroxicosis, sepsis, AMI, but rate-slowing therapy should NOT BE WITHHELD unless somehow contra-indicated.

I appreciate that this may be the view of some cardiologists to take the 'wait and see approach', but this is not consistent with international guidance.

Hence, in Japan, although the diagnosis can readily be established, the emergency treatment still needs to be effectively provided and based on current evidence and through step-by-step protocols that any level of doctor can follow.

Senior doctors need to maintain their knowledge base through paper reviews and using the most up-to-date of medical texts, as these days, therapeutics are rapidly changing and hence, so should the medical practices in Japan.

Teaching the junior doctors the right way through evidence based medicine is the only way to improve acute and continuing therapy and having seniors available who know how to effectively treat the patient by putting this knowledge into practise and guiding their junior physicians.

I reiterate again, that it is best to carry a PDA where quick access to electronic books can be effected such that stardardised medical therapy can be provided at the bed side with confidence that the junior doctor is doing the job correctly.

Fluid Balance, Drugs and Heart Failure

I have recently heard of some cases of worsening heart failure that have resulted from the underlying disease of heart failure but also due to under treatment with diuretics and over administration of fluid.

For example, a young female admitted to another hospital with acute oliguric renal failure from sepsis was being provided over 2.5 litres per day in IV fluid and she was unable to be extubated due to acute heart failure, bilateral effusions and type 1 respiratory failure.

She required daily haemofiltration to remove the excessive fluid but this was still insufficient to treat the problem. It was clear that fluid balance needed to be controlled. In a usual healthy patient, daily 'insensible losses' e.g. fluid loss from breathing, sweating and loss in faeces is approximately 500ml in a stable condition. This will increase in pathological conditions e.g. fever, hot conditions, diarrhoea etc.

In the absence of urine production such as in acute oliguric renal failure, in order to attain the status quo, fluid input should match fluid output through considering insensible losses once euvolaemic. This may be quite difficult to acieve especially when intravenous drugs need to be given plus nutrition. However, it is of importance to help control acute heart failure and hypertension which are obvious problems.

Furosemide was also given by the attending physician in this setting but proved ineffective in stimulating urine output and this is in keeping with the observations that Furosemide is not associated with any significant clinical benefit in the prevention and treatment of acute renal failure in adults and with high doses being associated with ototoxicity. BMJ 2006;333:420-3.

After taking advice, the attending physician in reducing the fluid input and continuing daily haemofiltration, the acute heart failure with effusions reduced so that the patient could come off the ventilator.

An example at the other end of the spectrum, was in an elderly patient at another hospital with heart failure who had presented with 'asthma'. She had a history of heart failure and had been treated for asthma with steroids for one month but she developed recent worsening respiratory function which suggested that the cause was perhaps 'cardiac asthma' from her underlying heart failure.

She was using BIPAP and the Xray showed a mixture of CHF and infection. MRSA had been identified in 3 out of six blood cultures. One concern was she was also receiving over 1 litre of intravenous fluid per day and daily furosemide dose was just 20mg/day with only an additional furosemide dose if the urine output decreased below 100ml/hour.

This is not standard treatment for heart failure as you either diurese a patient to reduce fluid or if dehydrated, given judicious fluids to maintain kidney function, but not both at the same time otherwise there will never be an accurate and continued fluid loss.

This is a bit like filling a container from the top but opening the tap from below and hoping to keep the fluid level the same. In other words, the heart failure will not be effectively treated.

When a patient is fluid overloaded with a background of cardiac failure, such patients need fluid restriction to approximately 500ml orally (see insensible losses above) per day to ensure that they go into a NEGATIVE fluid balance through diuresis, that we commonly refer to as 'drying out the patient'.

Patients should be weighed daily to ensure sustained weight loss and a general rule is to lose approximately 1kg per day in excess fluid unless renal dysfunction occurs in which case a slower diuresis can be effected.

Patients should also have no added salt in their diet. If IV fluids are to be given, they should not contain sodium, and hence, dextrose should be provided. ACE inhibitor or ARB therapy should started and Spironolactone considered (to treat secondary hyperaldosteronism) if the patient has excess oedema and the CHF does not respond to the ACE-I/ARB alone.

Moreover, it is somewhat dangerous to have ACE-I/ARB plus Spironolactone used together as it may cause worsening renal dysfunction and HYPERKALAEMIA especially in the elderly who tend to suffer with heart failure the most. However, close monitoring of renal function should be instituted. Spironolactone reduces mortality from CHF so its use should be considered.

Patients commonly need intravenous furosemide at much higher doses than 20mg/day, and I am used to giving at least 40 to 160mg of furosemide per day to patients on a case-by-case basis to establish a controlled cardiac state. As oral bioavailability of furosemide is only about 50% and that this may be reduced further from gastric oedema in heart failure, it is always preferable to give intravenous furosemide in advanced heart failure.

A very good question was 'What about the patient having low blood pressure'.

Well, if one considers why the patient has low blood pressure, the answer can be simply made. In heart failure with systolic compromise (rather than the diastolic compromise), the more the ventricle is over stretched, the less the muscle can contract (Starling Effect) and hence blood pressure may decrease despite rises in heart rate and central venous pressure. As there is a high output of aldosterone and catecholamines, a low blood pressure in the absence of another cause, suggests poor cardiac function.

Renal failure in CHF is contributed from the vasoconstrictive effect, and hence by reducing the ventricular filling and improving the ejection fraction in theory, the vasoconstrictive effect should be reduced leading to better renal perfusion and better diuresis.

In advanced heart failure, injection of furosemide causes a greater release of renin and plasma norepinephrine resulting in vasoconstriction but with an acute initial drop in ventricular function and rising filling pressures. However, blood pressure increases. This is an acute effect of furosemide injection seen in the first hour. Ann Intern Med 1985 Jul;103(1):1-6

In such cases of low blood pressure, counter-intuitively, furosemide causing diuresis, can aid in raising the blood pressure. However, furosemide can also cause venodilatation, similar to the venous morphine-effect, and can drop the blood pressure further especially if blood pressure is dependent on heart rate and raised central venous pressure when there is poor ventricular function, and so using it alone may be problematic especially when it is not known which are the greater contributors to maintaining the blood pressure.

It is likely that there is an interplay between venodilatation, vasconstriction (from secondary hyperaldosteronism), diuresis and reduction in circulatory volume thereby reducing pre-load and after-load with the use of furosemide.

However, if patients have severe cardiac failure and low blood pressure (shock) they essentially have cardiogenic shock, and ionotropes can be used to support such patients in the short term such as Noradrenaline, Dobutamine or High Dose Dopamine.

It should be mentioned at this juncture that despite the beneficial blood pressure elevating effects of inotropes, they have not been shown to improve survival.

CPAP is also a good short term measure of aiding heart failure and improving oxygenation, BUT if patients have low blood pressure, such non-invasive ventilation can worsen BP control and hence such therapy may be relatively contra-indicated.

Providing renal dose dopamine to ensure continued renal perfusion is of unproven benefit (Lancet 2000; 356: 2139-43) and the general opinion based on current evidence is not to use renal-dose dopamine in renal failure (UpToDate 15.1: Use of vasopressors and inotropes; Intensive Care Med 1996 Mar;22(3):213-9)

Hence, in this patient, the suggestion was to reduce daily fluid administration and to increase the daily amount of furosemide with the consideration to curtail unproven therapies such as renal-dose dopamine.